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Sem 4 - Case 3
The Man with Serious Indigestion Problems David Tipple is 40-years old and works as a wine importer. He drinks and smokes heavily and greatly enjoys his job because it gives him ready and inexpensive access to good wines. David visits his GP complaining (amongst other things) of intermittent severe indigestion, which he has had for the past 6 years. He describes episodes of a boring, dull pain, diffusely felt in both his upper abdomen and also in his back. The pain varies in severity, becoming worse shortly after eating a fatty meal, and on the day after a large intake of alcohol. He has tried antacids to no avail, but gets relief from analgesics (aspirin and paracetamol) which he uses freely. He is resigned to his indigestion, but recently other worrying symptoms have developed that, he complains, interfere with his lifestyle - hence this consultation. They include a form of diarrhoea. His faeces are bulky, greasy, the colour of putty, and excessively foul smelling. They float and hence are difficult to flush away, leaving an oily scum in the lavatory pan. He is producing excessive flatus. An oily faecal stain sometimes appears on his underpants. He feels weak and tired all the time. He believes that he is eating as much as before, but has lost 13 kg of weight from his previous 77 kg (170 lb). On examination, diffuse tenderness of the upper abdomen is present, as well as muscle wasting and peripheral oedema. When questioned about alcohol consumption (including the CAGE questions), David, who is frightened of being judged, grossly under-declares the quantities he consumes and flatly denies being alcoholic. The GP concludes that referring David to the local district general hospital is an appropriate next step although she is concerned that unless he makes lifestyle changes he could be denied treatment. At the hospital, a series of specialized investigations are performed to help the diagnosis. David is managed conservatively. He tries to cut down on his alcohol consumption, but much of his social life revolves around meeting friends at pubs and wine-bars. Eventually he is persuaded to visit an Alcohol Advice Centre, where he is given counselling and practical advice. David manages to cut down his consumption considerably which requires a substantial change in lifestyle and especially in health cognitions. However, he finds it hard to follow the strict total abstinence of Alcoholics Anonymous. Pancreatin is given with food, as well as cimetidine 1 hour beforehand. Soreness of the skin develops around his mouth and anus, but subsides when dietary fat is restricted to 25% of total calorie intake, and the dose of pancreatin is reduced. David’s faeces return to normal and he regains his lost weight and vigour. If he continues to abstain from alcohol his physical condition may not deteriorate. ILOs *Knowledge of the responsibility for our own health theory *To demonstrate basic knowledge of how to differentiate between gastric and pancreatic function *To demonstrate basic knowledge of the clinical investigation of the GI tract *To demonstrate basic knowledge of the pathophysiological effecet of alcohol addiction *To demonstrate basic knowledge of the services available for people with alcohol related problems *To demonstrate knowledge of how pain is sensed in the abdomen and the anatomical/physiological basis of referred pain *To demonstrate knowledge of the effect of malnutrtion on physiological function *To demonstrate knowledge of the movement of water and electrolytes across the gut wall *To demonstrate knowledge of the public health problems associated with alcohol abuse *To demonstrate knowledge of the structure and function of the pancreas *To demonstrate understanding of the basis of prioritising in health care University Resources Please note that these may require you to log in to blackboard to access them. You can visit the full resource page for the case here, otherwise here are some of the main ones. Case Resources *Lifestyle and behaviour change - Chris Bundy *Ogden Health Pscyhology - **pp38-9 and 48-54 for health beliefs **pp65-77 for psychological theories of addiction **pp106-114 for deveopmental model of eating behaviour Lectures *Alcohol use and abuse: A clinical perspective - Ray McMahon *Alcohol use and abuse: A public health perspective - Paula Whitaker *Clinical overview of diseases of the exocrine pancreas - Katharine McWhirter